An average of 90 patients are admitted monthly to the hospital by the Family Medicine Center in Fort Collins. A few years ago, about 50 of those patients would have been readmitted to the hospital within 30 days of being treated.

Social and economic barriers — from lack of transportation and homelessness to mental illness and illiteracy — prevented these patients from following through with the health care plan laid out by FMC. But that’s not the case anymore thanks to the creation of FMC’s Transitional Care RN program in 2013.

“Every year, the care we provide gets more and more complex, and more specifically, it gets more acute,” said Dr. Bernard Birnbaum, FMC’s associate residency director, who spearheaded the new team. “Although our uninsured rate drastically plummeted with the Affordable Care Act, our patients’ socioeconomics haven’t changed. We needed to be able to identify those needs to make it more likely for these patients to get better care.”

Transitional Care Team registered nurse Jennifer Nolte explained further: “When you don’t have basic needs met, health won’t be your priority. We had to look at the holistic health of a patient.”

The team includes two full-time registered nurses — Nolte and colleague Andrea Hooley — based out of UCHealth Poudre Valley Hospital. Nolte and Hooley began the program by creating a tool to identify barriers that their patients were facing. The modified risk assessment tool had often been used by hospitalist programs, but never before within a residency program, Nolte said.

Every person admitted to the hospital by either FMC or its affiliate clinic, Salud Family Health Centers, with the exception of people from long-term care facilities, is screened using the risk assessment tool. This tool identifies barriers to health care that may be caused by socioeconomic factors, psychological issues, addiction, isolation or being a non-English speaker. And it helps to recognize if the person has poor health literacy, inadequate chronic disease management or medication issues.

“A common situation is where a person has several of these factors lighting up on their assessment,” Hooley said.

Hooley and Nolte use their assessment information to help the resident doctors better understand their patients. (FMC is a training site for the Fort Collins Family Medicine Residency Program.) But just as important, the information is used to help Hooley and Nolte during the patient’s discharge process. It’s at that time that the two nurses use their extended experience in socioeconomic issues to address anything that may make it difficult for the patient to follow through with their health plan — a plan that now always includes a follow-up visit.

“The most important thing we do as physicians is take care of people’s health issues but to do that we need to know the needs of the patient, and unfortunately, this has become harder and harder to do,” Birnbaum said. “It does no one any good to give a patient a treatment plan that they have no way to comply with. But with this transitional care program, we can meet the patient where they are.”

Based on the screening, Hooley and Nolte can find specific interventions to help patients to better focus on their health. They connect patients to UCHealth programs such as with case managers or to the PVH EMS Community Paramedics program, as well as to outside resources, such as the food bank or a shelter.

“Our sole purpose is to decrease admissions [to the hospital] and increase quality of life,” Nolte said. “We try to link them to resources they need. For example, Medicaid provides free transportation, and a lot of these people don’t realize they have those benefits.”

A key component to the transitional care program’s success is the one-on-one time Hooley and Nolte spend with each person explaining their health care plan and the importance of the follow-up visit — a visit that also gives FMC an opportunity to see if their interventions are helping.

“Because we are a residency program and there can be a lot of different people by the patient’s bedside, it’s important for us to explain the plan,” Nolte said. “We provide specialized education on their diagnosis and medication, and we make sure they understand any changes or additions to their plan. … We advocate for that patient.”

And in turn, their patients are returning to the hospital less often – nearly half, according to two-year data.

“The reality is if we can identify the factors that lead to poor follow-up and poor reoccurrence of care, then they get better care and have better outcomes,” Birnbaum said. “Readmissions are a surrogate marker and a secondary goal here. What we are really trying to do is make lives better.”

About the author

Kati Blocker has always been driven to learn and explore the world around her. And every day, as a writer for UCHealth, Kati meets inspiring people, learns about life-saving technology, and gets to know the amazing people who are saving lives each day. Even better, she gets to share their stories with the world.

As a journalism major at the University of Wyoming, Kati wrote for her college newspaper. She also studied abroad in Swansea, Wales, while simultaneously writing for a Colorado metaphysical newspaper.

After college, Kati was a reporter for the Montrose Daily Press and the Telluride Watch, covering education and health care in rural Colorado, as well as city news and business.

When she's not writing, Kati is creating her own stories with her husband Joel and their two young children.